A cadaver study evaluating intraluminal anomalies of the left common iliac vein

OBJECTIVE

Intraluminal anomalies within the left common iliac vein, characteristic of iliac vein compression syndrome, are thought to result from compression by and pulsation of the overlying right common iliac artery. This cadaver study was designed to expand on the existing literature by surveying and photographing these spurs in addition to exploring whether certain factors, inherent to the cadaver, are associated with spur presence.

METHODS

Dissection to expose the aorta, inferior vena cava, and common iliac arteries and veins was performed in 51 cadavers. The spinal level at which the iliac vein confluence occurred was noted. The point at which the right common iliac artery crossed the left common iliac vein was examined for plaque presence. The overlying arterial structures were then transected to expose the venous system. The inferior vena cava was incised to facilitate observation into the mouth and full extent of the left common iliac vein. Spurs were photographed and documented. Statistical analysis was conducted to determine whether sex, body mass index (BMI), plaque presence, or level of the iliac vein confluence are associated with spur presence.

RESULTS

Spurs within the left common iliac vein were observed in 16 of 51 cadavers (31.4%). All spurs were located at the point that the right common iliac artery crossed the left common iliac vein. Using1 the classification system established by McMurrich, 67% of spurs (n = 10) were marginal and triangular; 25% (n = 4) were columnar. One marginal, linear spur (6%) and one partially obstructed spur with multiple synechiae (6%) were observed. Among this population, males were 73% less likely to have a spur (odds ratio, 0.269; P = .041). No significant relationship was found between plaque presence and spur presence (odds ratio, 0.933; P = .824) and no significant differences were noted between BMI and spur presence (χ2 = 1.752, P = .625). Last, a significantly greater percent of spurs was found within cadavers with an iliac vein confluence located at the L5/S1 disc space (χ2 = 9.650; P = .002).

CONCLUSIONS

Study findings show that spurs are more common when the confluence of the common iliac veins occurs at a lower spinal level. The level of the iliac vein confluence may be important in identifying patients at increased risk of venous disease. The findings also suggest that plaque within the right common iliac artery and BMI display no distinct relationship with spur presence. Further investigation is needed to understand exactly what factors lead to spur formation.

Interrupted inferior vena cava draining into the coronary sinus associated with circumflex artery to coronary sinus fistula

In an adult patient, coronary artery fistula involving the circumflex artery (CX) connected to the coronary sinus caused aneurysm of the left main and CX associated with ectasia of the intermediate branch. The patient had posterolateral infarction with severe ischemic mitral regurgitation and moderate tricuspid regurgitation. A rare venous return anomaly was also present. The inferior vena cava, which was interrupted at the level of the liver, continued with the hemiazygos to drain into a persistent left superior vena cava, which in turn drained into the coronary sinus. Surgery included CX closure and mitral and tricuspid repair. The strategy had to be adapted to the anatomy. The fistula was dissected and snared for cardioplegia delivery, and venous return was achieved by cannulation of the superior vena cava and femoral vein. The procedure was uneventful, and 4 years later the patient is asymptomatic.

STIC-HD live flow technology in the antenatal diagnosis of scimitar syndrome: A case report

Scimitar syndrome (SS) is a rare entity with an incidence of approximately 1-3 in 200 000 people. It is typically characterized by complete or partial anomalous pulmonary venous drainage from the right lung into the systemic venous circulation, most commonly the inferior vena cava (IVC). For the first time, we report the diagnosis of SS in a fetus in utero using four-dimensional (4D) spatiotemporal image correlation combined with high-definition live flow rendering mode (STIC-HD live flow).

Laparoscopic para-aortic lymphadenectomy for metastatic colon cancer in a patient with left-sided inferior vena cava: a case report

Transposition of inferior vena cava, or, left-sided inferior vena cava (LS-IVC) is a rare clinical entity, in which the inferior vena cava ascends along the left side of the abdominal aorta. Literature contains mainly clinical case reports. Although it is usually not associated with clinical symptomatology, this anomaly should be detected during preoperative planning to avoid iatrogenic injuries intraoperatively. We present a case of left-sided inferior vena cava encountered during laparoscopic lymphadenectomy in a 45-year-old man with previous laparoscopic hemicolectomy due to colon adenocarcinoma. Preoperative CT abdomen revealed the left-sided location of infrarenal IVC and laparoscopic trans-peritoneal aortic lymphadenectomy was decided. Intraoperatively, transposition of inferior vena cava was confirmed in accordance with the CT findings. Resection of lymph node block was conducted with no complications and with minimal blood loss. The postoperative course was uneventful, and the patient was discharged from the hospital the day following surgery. In conclusion, transposition of the inferior vena cava, although rare, constitutes an anatomical variant that should be identified preoperatively to decrease intraoperative risks. Several anatomical variants have been associated with left-sided inferior vena cava.

[Importance of prenatally diagnosed portosystemic vascular shunts in clinical outcomes]

Portosystemic venous shunts (PSVS) are malformations that result from abnormal communications between the portal and hepatic veins or inferior vena cava. Prenatal diagnosis is made by evaluating the fetal venous circulation and it is classified as intrahepatic and extrahepatic, with different evolution and complications.

OBJECTIVE

To report two cases of prenatal diagnosis of portosystemic vascular shunts and review the importance of this rare pathology in its neonatal and pediatric evolution.

CLINICAL CASES

Case 1: pregnancy with fetal growth restriction, 2nd percentile, polyhydramnios, without fetal malformations and abnormal patterns on fetal Doppler. Abnormal blood flow through the ductus venous and abnormal venous communication in the liver were identified. Normal genetic study. Male newborn (NB) delivered at 36 weeks, because of severe fetal growth restriction, by emergency cesarean section. He evolved asymptomatic, with normal liver function, and did not continue follow-up. Case 2: pregnancy with fetal growth restriction < percentile 1. Agenesis of the ductus venous and abnormal communication between the portal vein and the left suprahepatic vein were identified with no other malformations or signs of heart failure. Severe SGA newborn was delivered by induction of labor at 35 weeks. He evolved asymptomatic. Normal complementary study. A home check-up at 2 months showed persistent vascular anomaly without systemic involvement.

CONCLUSIONS

Even though in the cases presented there were no neonatal complications, this kind of malformations require a high index of suspicion in cases with fetal growth restriction, as well as a long-term multidisciplinary follow-up.

A remarkable case report of an interrupted inferior vena cava with hemiazygos and transhepatic continuation

Inferior vena cava (IVC) interruption with azygos/hemiazygos continuation is an extremely uncommon congenital vascular anomaly, which may present with multiple variants. As a result, it is challenging to find in the literature the same anatomical variant. We report a unique case of an interrupted IVC with hemiazygos and transhepatic continuation in an 83-year-old female patient. The case was evaluated by performing Computed Tomography (CT) as imaging modality, with a multiphase protocol, able to detect accurately this complex vascular anomaly. The purpose of this case report is not only to present this remarkable case but also to briefly show the types of interrupted IVC, starting from the anatomy and the embryology of the IVC and the azygos system, and to discuss the value of imaging in detecting the vascular anomaly.

Intra-abdominal haemorrhaging after cardiac catheterisation: the importance of recognising vascular anomalies in heterotaxy syndrome

A 2-month-old boy with a single ventricle underwent cardiac catheterisation. Inferior vena cava angiography at the end of the examination revealed local stenosis, flexion, and connection to the right hepatic vein. Six hours after catheterisation, he went into haemorrhagic shock. CT revealed contrast extravasation into the liver with ascites. A precise diagnosis of vascular anomalies is mandatory, especially in patients with heterotaxy syndrome.

Inferior Vena Cava agenesis presenting as deep vein thrombosis in an eight year-old girl

Agenesis of vena cava inferior (AVCI) is a rare congenital malformation with a prevalence of 0.0005-1% in the general population. High level of suspicion is required in young patients with deep vein thrombosis (DVT), particularly bilateral. We present an 8-year-old girl with AVCI presenting as bilateral lower extremity DVT and a review of the literature in pediatric cases with AVCI and DVT.

Direct Oral Anticoagulants for Inferior Vena Cava Agenesis

Deep vein thrombosis (DVT) is common in the general population, with an annual incidence of 1 to 2 per 1000 people. Inferior vena cava agenesis (IVCA) increased the risk of developing DVT and is found in approximately 5% of young adults (20-40-year-olds) diagnosed with unprovoked proximal DVT. IVCA can be caused by a defective embryological process, or be a result of intrauterine or perinatal thrombosis. Its estimated incidence in the general population ranges from 0.0005% to 1%, usually involving a partial absence of one of the four segments of the inferior vena cava (IVC). The management during the extended phase of patients with DVT associated with IVCA is not yet harmonized, as it is poorly described in the literature. Patients with IVCA are considered to be at high risk of DVT occurrence, prompting physicians to continue extended anticoagulation, often using vitamin K antagonists. In this retrospective study, we present a cohort of 11 patients diagnosed with IVCA following a DVT, who subsequently received extended treatment with a direct oral anticoagulants. These findings offer reassuring insights into the extended utilization of direct oral anticoagulants, demonstrating both antithrombotic efficacy and a favorable safety profile.

Anomalous drainage of the right gonadal vein

The present research aims to present and describe an unusual and rare anatomical variation in relation to the drainage of the right gonadal vein. This anatomical knowledge is crucial as it assists in the work of surgeons and health professionals in general. The dissection occurred in the anterior wall of the abdomen and, through observational analysis, an anatomical variation was found in the drainage of the right gonadal vein in a human cadaver, obtained by anonymous donation, male gender and without predetermined clinical characteristics, ethnicity, and age, belonging to the Padre Albino University Center collection. This research was approved by the Research Ethics Committee under protocol 12923919.8.0000.5430. The drainage of right gonadal vein is this variant occurs anastomosed with an innominate venous trunk that empties into the inferior vena cava. Furthermore, the presence of an accessory right renal vein is also noticed, which anastomoses with the innominate venous trunk and with the right renal vein, through a vein suggestively called interrenal, differing from the anatomical normality described in the literature. This variation is supposed to occur due to flaws in the development of the embryo, which generate venous changes in the origins of the right gonadal vein. Acknowledging the existence of it is relevant when performing surgical procedures in the region, as it differs from the most frequent anatomy found in the human population. The rare drainage of the right gonadal vein through an innominate trunk to the inferior vena cava and its importance is highlighted in this article.

One filter may be enough for duplicate inferior vena cava filter implantation in patients with deep venous thrombosis: Two cases report

BACKGROUND

Duplicate inferior vena cava (IVC) is an uncommon congenital malformation, but should be treated carefully under the circumstances of deep venous thrombosis (DVT). However, there is a paucity of clinical guidance on this situation.

METHODS

Duplicate IVC was diagnosed based on the imaging examination that revealed the dual IVC. Deep venous thrombosis was diagnosed by Compression Doppler ultrasonography of both lower extremities with the high-elevated D-dimer. Retrievable IVC filters were implanted to prevent massive and fatal pulmonary embolism. Appropriate anticoagulation therapy was also performed.

RESULTS

Two retrievable filters were successfully implanted and retrieved in two patients with deep venous thrombosis and duplicate inferior vena cava, respectively. During further follow-up, no adverse event was reported.

CONCLUSION

Comprehensive imaging examination might contribute to the diagnosis of duplicate IVC, especially when individual conditions were limited. The position above the confluence of bilateral IVCs might be an appropriate suprarenal retrievable filter insertion location. To deal with different types of dual IVC anatomy, different strategies should be taken into consideration.

Prenatal diagnosis of hepatic interruption of the inferior vena cava with azygos/hemiazygos continuation without structural heart defects: A case series

OBJECTIVES

To describe fetal spectrum and echocardiographic characteristics of interrupted inferior vena cava (IIVC) with azygos/hemiazygous continuation without other structural heart defects and to evaluate its association with visceral heterotaxy and isomerism, extracardiac and genetic anomalies, and to review neonatal outcome.

METHODS

This was a retrospective study of 14 fetuses with a confirmed diagnosis of IIVC with normal intracardiac anatomy. The following variables were collected; indication for referral, gestational age at diagnosis; associated isomerism and visceral heterotaxy, heart rhythm, genetic and extracardiac abnormalities, and fetal/neonatal outcome.

RESULTS

Among 36 fetuses with IIVC, 14 cases (38.8%) had normal intracardiac anatomy. These IIVC cases correspond to 0.19% (14/7250) of all fetal cardiac examinations, and to 1.5% (14/922) of all cardiac abnormalities. Six patients had visceral abnormalities. Atrial appendage morphology was clearly depicted in three fetuses, both appendages were left. One fetus had bradyarrhythmia revealing atrial ectopic rhythm. Six fetuses did not have any concomitant cardiac or visceral abnormalities, therefore regarded as isolated. All babies were delivered at term with a good prognosis.

CONCLUSION

Our study has shown that almost half of the IIVC cases without intracardiac structural anomalies displayed other findings of isomerism while the other half was isolated benign vascular variant. Therefore, prenatal diagnosis of IIVC should prompt a comprehensive evaluation for cardiac, situs, and visceral anomalies. The outcome is favorable.

Duplication of the inferior vena cava: a case series

The inferior vena cava (IVC) may develop abnormally because of its complex embryogenesis. An understanding of congenital variants such as duplication of the IVC is essential for clinical interventions, particularly those performed by surgeons and radiologists. We herein describe five patients who were diagnosed with duplication of the IVC by computed tomography or angiography and summarize their imaging and clinical features. All five patients were men aged 46 to 78 years. Two of the patients had pulmonary embolism and deep vein thrombosis and were treated by placement of an IVC filter and catheter-directed thrombolysis. The IVC in all patients ascended on either side of the abdominal aorta. All left IVCs terminated in the left renal vein, which crossed the aorta and joined the right IVC. The average follow-up time was 29 months (range, 14-46 months), and no patients developed venous thromboembolism or recurrence of thrombosis. Duplication of the IVC can be diagnosed by computed tomography and angiography. Its course and relationship with the renal vein must be identified for accurate planning of IVC filter placement in the setting of deep vein thrombosis and pulmonary embolism.

Rare case of mesocardia with ostium secundum ASD and double IVC

We report an extremely rare case of mesocardia with double inferior vena cava (IVC) in this case report. The patient's associated atrial septal defect (ASD) with left to right shunt leading to pulmonary congestion and recurrent episodes of pneumonia was the leading diagnosis for which care was sought at our hospital. The diagnoses of these rare congenital cardiac anomalies were uncovered only after a thorough workup. Mesocardia is extremely rare and accounts for only 0.2% of congenital anomalies. Its association with other cardiac and vascular anomalies, however, warrants a meticulous workup for the identification of such associated conditions-ASD and double IVC being two such anomalies in our patient. The dictum of working up a case of congenital cardiac anomaly for other congenital cardiaovascular anomalies, therefore, found merit in our case.

Rare congenital abnormality resulting in spontaneous bilateral deep venous thrombosis and pulmonary emboli in a young healthy man

This report describes a unique case of a healthy man in his 30s, who presented with progressive unilateral leg swelling with no common risk factors identified. Two days prior to the swelling he had developed significant abdominal pain following a treadmill exercise session. Ultrasound imaging revealed extensive deep vein thrombosis involving bilateral ileo-femoral venous systems, extending up the inferior vena cava (IVC). Further investigation using a CT venogram revealed the rare congenital anomaly of hypoplasia of the renal IVC. Successful treatment involved 48 hours of an intravenous unfractionated heparin infusion, followed by lifelong anticoagulation.

Unique Medley of Cardinal Veins: Duplicated Superior and Inferior Venae Cavae With Left Renal Agenesis and Hemiazygos Continuation of Left Inferior Vena Cava With Drainage Into Left Atrium

Congenital anomalies of the superior and inferior vena cava result from abnormal embryogenesis of cardinal veins. Duplication of superior vena cava (SVC) occurs in 0.3% of the general population of which only 8% drain into the left atrium. The prevalence of double inferior vena cava (IVC) is around 0.2-3%. The reported incidence of unilateral renal agenesis ranges from 1:1100 to 1:5000, and the association of double IVC with renal agenesis has been reported in only 11 cases in the literature. The conglomeration of such rare anomalies incidentally noted in a single patient is reported in this study. A 32-year-old man was referred to our department for Computed Tomography (CT) scan of the thorax. The patient was found to have dorsal kyphoscoliosis with hemivertebrae. The SVC was duplicated with the right SVC draining into the right atrium and the left SVC draining into the left atrium. The left kidney was not visualized in the abdomen. There was dual IVC with no intercommunicating interiliac vein. The right IVC maintained its normal course, while the left IVC continued as hemiazygos vein and joined left SVC in the thorax. Also noted was the aberrant origin of the right subclavian artery. This is the first reported case of combined superior and inferior vena caval anomalies along with left renal agenesis in a single patient in the literature. A review on the embryological basis is also described in this article.

The anomalous drainage of the inferior vena cava into the left atrium

BACKGROUND

Anomalies in systemic venous return most commonly involve a persistent left supe-rior vena cava draining into the left atrium. Anomalous drainage of the inferior vena cava (IVC) into the left atrium is a rare congenital vascular disorder. The diagnosis was confirmed as anoma-lous drainage of the right superior pulmonary vein and large atrial septal defect following echo-cardiography. Anomalous drainage of the inferior vena cave was confirmed with computed tomog-raphy (CT). We report a rare combination of drainage of the inferior vena cava associated with atrial septal defect (ASD) and partial anomalous pulmonary venous return.

CASE

A 14-year-old girl was referred to our hospital for the evaluation of palpitations, hypoxia, exertional dyspnea, and cyanosis. Transthoracic echocardiography (TTE) revealed a large sinus venosus ASD and anomalous right superior pulmonary venous return. A cardiac CT demonstrated IVC drainage to the left atrium and an anomalous right superior pulmonary vein draining into the right atrium.

CONCLUSIONS

In older patients with cyanosis, further imaging methods together with TTE will be useful in detecting additional cardiac anomalies. Patients with inferior vena cava opening to the left atrium are different from caval type ASD`s and should be surgically repaired using a patch. Corrective surgery involves repositioning of the interatrial septum via a patch.

A Rare Variant of Hypogenetic Lung Syndrome Mimicking Scimitar Vein

Hypogenetic lung syndrome, also known as scimitar syndrome, is a rare and well-known congenital condition that includes hypoplastic right pulmonary artery and lung, right displacement of the heart, anomalous systemic arterial supply to the lung, and a characteristically curved anomalous right pulmonary vein draining into the inferior vena cava. In exceptional cases, the anomalous pulmonary vein may drain into left atrium. We here report a case of a 17-year-old girl with a rare variant of hypogenetic lung syndrome diagnosed by means of multimodality imaging and treated with percutaneous occlusion of the aortopulmonary collateral.

Duplication of Inferior Vena Cava, Possible Cause of Internal Hernia? Literature Review and Rare Case Presentation

Duplication of inferior vena cava (DIVC) is a rare congenital malformation of extreme importance for vascular and urology surgeons, interventional radiologists. Oftentimes it goes unnoticed and is diagnosed incidentally at a routine or emergency CT-scan when complications occur due to associated congenital malformations. We present a case of a 70-year-old male patient who was admitted into the emergency room (ER) accusing abdominal pain. He was diagnosed with an intestinal obstruction due to a left paraduodenal hernia (LPDH), associated with a DIVC. The reviewing the literature led to concluding that DIVC is not the cause of LPDH.

Duplication of the inferior vena cava: evidence of a novel type IV

Anatomical variations of the inferior vena cava, including the double inferior vena cava or isolated left inferior vena cava, are uncommon and of great clinical importance. Inferior vena cava variations signify predisposition to deep vein thrombosis and may complicate retroperitoneal surgeries including abdominal aortic surgery. Failure to recognize such variations may predispose a patient to life- threatening complications. This prospective anatomical study assessed 129 cadavers for variations of the inferior vena cava. One of the 129 cadavers (0.78%) possessed a double inferior vena cava and none (0%) possessed an isolated left inferior vena cava. The left-sided inferior vena cava was of a larger diameter than that of the right-sided inferior vena cava - opposite of what would be seen in a Type III duplication. Therefore, this observation expands the three-type classification system to include a Type IV duplication.

A case report of ectopic pregnancy arising in a unicornuate uterus, accompanied by the undescended tube and ovary with double inferior vena cava

RATIONALE

The incidence of a unicornuate uterus is 0.2% to 0.3% of the whole population. A unicornuate uterus is closely associated with obstetrical complications such as early miscarriages, ectopic pregnancy, and malpresentation.

PATIENT CONCERNS

A 32-year-old patient developed a rare ectopic pregnancy arising at a distal, fimbriated end of the undescended fallopian tube.

DIAGNOSES

A transvaginal ultrasound scan revealed hemoperitoneum and no gestational sac in the uterine endometrium. A laparoscopic finding showed that high up in the right abdomen, just below the liver, an ectopic mass could be seen arising at a distal, fimbriated end of the fallopian tube, which was developed adjacent to the undescended right ectopic ovary.

INTERVENTIONS

After laparoscopic removal of the right salpinx, we removed it with a bag.

OUTCOMES

One day after the operation, she was discharged without problems. Postoperative hysterosalpingography showed the unicornuate uterus with patent left and some right salpinx. Magnetic resonance imaging revealed a unicornuate uterus, right ovary at the right inferior hepatic area, a bilateral normal kidney, and double inferior vena cava.

LESSONS

This is the first reported case of its type. It demonstrated that ectopic pregnancy may occur in the upper abdomen, not in the pelvic cavity, in uterine anomaly, and double inferior vena cava; hence, we must thoroughly check the whole abdominal cavity. Additional imaging tests are needed after treatment to see if there are any abnormalities.

Case Report of a Pelvic Crossed Fused Renal Ectopic Kidney

Herein we present a case of a horseshoe kidney with crossed fused renal ectopia. Both of these pathologies are congenital anomalies; however, to date, there are few cases that present with both. In this case, discovered during routine dissection, the fused kidney was mostly left-sided and very low in the pelvis. No renal artery arose from the right wall of the abdominal aorta, and the right renal vein drained into the lower part of the inferior vena cava (IVC) where the right and left common iliac veins joined. It is essential for clinicians and surgeons to understand these types of congenital anomalies, as they could impact patient care.

Abdominal Aortic Aneurysm Repair Requiring Left-Sided Inferior Vena Cava Interposition

BACKGROUND

Left-sided inferior vena cava (IVC) is a rare congenital venous anomaly. We describe a case of open repair of a nonruptured abdominal aortic aneurysm (AAA) in a patient with left-sided inferior vena cava requiring IVC transection and reconstruction with interposition graft.

CASE REPORT

A 56-year-old man presented for elective repair of a 6.2-cm AAA with preoperative imaging demonstrating a left-sided IVC. Intraoperatively, IVC crossing at the aneurysm neck conferred inadequate exposure for arterial anastomosis. After transection of the IVC, the AAA was repaired, and the IVC was reconstructed with a 24-mm Dacron tube graft. His recovery was uneventful, and grafts were patent at 3-month follow-up.

CONCLUSIONS

Left-sided IVC is a rare anomaly encountered during abdominal aortic surgery that presents technical challenges. Division of the IVC and reconstruction with interposition graft is a possible solution if other techniques fail to provide adequate exposure.

Spinal Epidural Hematoma After Attempted Catheter Thrombectomy of a Large Iliofemoral Deep Venous Thrombosis: A Case Report

The authors report the case of an 82-year-old woman with a spinal epidural hematoma following attempted catheter-directed thrombolysis of a large femoral- popliteal deep venous thrombosis. The patient rapidly developed acute motor and sensory paralysis below the level of T7 within hours of the thrombectomy procedure. Computed tomography imaging revealed that the catheter had perforated the wall of the right inferior vena cava and magnetic resonance imaging subsequently demonstrated an extensive T1-S1 dorsal epidural hematoma with compression of the thoracic spinal cord, conus medullaris, and cauda equina. Given the extent of cord infarction and the risks of extensive thoracolumbar laminectomy, decompression was not performed. The incidence, diagnosis, and management of anticoagulation- associated spinal epidural hematoma as well as the indications for catheter-directed thrombolysis of acute deep venous thrombosis are reviewed.

Transplantation of a Kidney With Duplicated Ureter Harvested From a Donor With Vascular Anomaly in the Form of Double Inferior Vena Cava: A Case Report

During the organ procurement procedure, a surgeon encounters anatomic anomalies not very often but also not uncommonly. These changes may put the success of the transplant into question. Despite the thorough diagnosis of the potential donor, these anomalies are often diagnosed during organ donation. In our paper we present a case of kidney transplantation with duplicated ureter. The organ was collected from a donor with duplicated inferior vena cava. After transplantation, the kidney functioned immediately. Taking into consideration the well-being of the recipient, organs with anatomic abnormalities should be carefully considered for transplantation. This is especially important when there is a constant shortage of organs for transplantation.

Undiagnosed inferior vena cava type of sinus venosus atrial septal defect in a middle-aged woman: A rare case report

Sinus venosus atrial septal defect (ASD) accounts for 5% to 10% of ASDs. In contrast with the more common superior vena cava (SVC) type, the inferior vena cava (IVC) type of sinus venosus ASD with overriding IVC is extremely rare. The sinus venosus defect occur posterior to the fossa ovalis and is not regarded as true ASD. Transesophageal echocardiography (TEE) is a diagnostic procedure of choice due to close proximity of atrial septum to TEE transducer. However; it may not constantly yield detailed anatomical and functional characterization, and other imaging modalities such as cardiac magnetic resonance imaging (MRI) may be needed. We report the case of a 45-year-old woman with an undiagnosed hemodynamically significant IVC-type ASD without any anomalous drainage of pulmonary veins, who presented with progressive dyspnea.

​Venous anomalies in renal transplantation: an accessory left-sided IVC in a live kidney donor

Duplication of the inferior vena cava (IVC) resulting in an accessory left-sided IVC is a relatively rare vascular anomaly with a reported prevalence of 0.7%. Radiologically, a duplicated left-sided IVC is usually seen as a continuation of the left common iliac vein, crossing anterior to the aorta at the level of the renal vein to join the right-sided IVC. We present a rare case in which an accessory left-sided IVC was discovered intraoperatively, in a 47-year-old living donor, posing significant intraoperative challenges regarding extraction and subsequent transplantation.

Left superior vena cava: cross-sectional imaging overview

Persistent left-sided superior vena cava (PLSVC) is the commonest systemic venous anomaly in the thorax with a reported prevalence of up to 0.5% in otherwise normal population and up to 10% in patients with congenital heart disease (CHD). In the absence of associated CHD, it is usually asymptomatic, discovered incidentally. It may complicate catheter or pacemaker lead placement. PLSVC typically drains into the right atrium through the coronary sinus. In children with CHD, the presence of a PLSVC may affect the choice of certain surgical procedures. PLSVC is significantly more common in association with situs ambiguous than with situs solitus or inversus, up to 60-70%. In patients with situs ambiguous, the drainage of LSVC is variable, more commonly directly into the atria rather than through the coronary sinus (CS). Rarely, there is a PLSVC draining into the CS with absent right SVC. PLSVC draining into the right atrium via the CS will not usually cause blood shunting between the right and the left sides. However, shunting occurs when PLSVC is associated with unroofed CS, or when it directly drains into the left atrium. With an increased use of CT and MRI for chest and cardiac imaging, PLSVC is being more encountered by radiologists than before. In this article, we will discuss the embryology of PLSVC, its anatomic course and drainage pathways, as well as its clinical relevance and relation to congenital heart disease and viscero-atrial situs.

Bilateral Deep Vein Thrombosis, Vena Cava Agenesis, and Renal Abnormalities: KILT Syndrome-A Case Report and Literature Review

KILT (kidney and IVC abnormalities with leg thrombosis) syndrome is a very rare condition that associates inferior vena cava abnormalities, renal defects, and venous thrombosis. These vascular disorders appear in 0.6-2% of patients with cardiovascular events and condition a venous stasis that contributes to the formation of thrombus in the lower limbs. Only a few cases of KILT syndrome have been published in the literature and the genesis, epidemiology, and natural history of the disease are yet unknown. We present a case of a 39-year-old man with no medical background who developed thrombosis of the inferior vena cava in its infrarrenal portion to both common iliac veins, all associated with agenesis of the rest of the vascular structure and an atrophic right kidney. The patient was treated with full anticoagulation, without the development of renal failure, postthrombotic syndrome, nor other complications. Thrombophilia study was normal, including mutations of prothrombin gene, factor V Leiden, and antiphospholipid antibodies. We hypothesize the benefit of an early diagnosis to improve the management of this condition. KILT syndrome must be taken into account in cases of proximal venous thrombosis, especially in young patients without risk factors for the development of thrombosis.

Ruptured inferior vena cava aneurysm in the setting of mural vascular malformation: A case report

Aneurysm of the inferior vena cava is a rare anomaly with a very few reported cases worldwide. We report the case of a 26-years-old man with acute severe abdominal pain and hypovolemic shock following an episode of syncope. Ultrasonography showed a fusiform aneurysmal dilation of the infra-hepatic inferior vena cava (IVC), with a large saccular portion at its posterolateral wall and mural thrombosis. Abdominal computed tomography scan revealed extension to the right renal vein and adhesion to the right kidney. The saccular aneurysm and the right kidney were resected, and anatomopathological examination revealed a cavernous hemangioma. All symptoms disappeared after surgery. This is the first reported case of symptomatic congenital saccular aneurysm of the IVC due to mural vascular malformation and with involvement of the right kidney leading to nephrectomy.

[Ultrasound diagnosis of left inferior vena cava and double inferior vena cava in fetus]

OBJECTIVE

To evaluate the application of ultrasonography in prenatal diagnosis of left inferior vena cava and double inferior vena cava in fetus.

METHODS

The clinical data and ultrasonographic findings of the fetuses with left inferior vena cava (18 cases) or double inferior vena cava (16 cases) were retrospectively analyzed.

RESULTS

The ultrasonographic images of left inferior vena cava showed that in the transverse view of the fetal upper abdomen the inferior vena cava and abdominal aorta were in the normal position; below the level of the hilum, the inferior vena cava was located behind the left side of the abdominal aorta; at the level of the hilum, it crossed the front of the abdominal aorta and run diagonally to the upper right, forming the right inferior vena cava and finally entered into the right atrium. The ultrasonographic images of double inferior vena cava showed that in the transverse view of the fetal lower abdomen, in front of spine there were three transections of blood vessels; in coronal plane of abdomen, the veins run on both sides of the abdominal aorta and entered to the iliac vein of the same side. In 34 cases of abnormal inferior vena cava, there were 17 cases complicated with other system abnormalities, including 13 cases of cardiac anomalies.

CONCLUSIONS

The left inferior vena cava and double inferior vena cava have characteristic imaging findings, and prenatal diagnosis can be made with ultrasonography. This type of congenital deformity is frequently complicated with other system abnormalities, which should be excluded in fetus, especially for heart system.

Surgical Repair of a 13-cm Infrarenal Abdominal Aortic Aneurysm with Aortocaval Fistula in a 63-Year-Old Tuba Player

Infrarenal abdominal aortic aneurysm with aortocaval fistula, a rare condition, can be fatal without prompt intervention. The clinical symptoms are complex and varied, so diagnosis is typically confirmed by use of contrast-enhanced multidetector computed tomography. We report our surgical repair of a 13-cm-diameter infrarenal abdominal aortic aneurysm and aortocaval fistula in a 63-year-old orchestral tuba player who had 2 classic symptoms of the condition. The unruptured aneurysm and fistula were complicated by acutely angled vessels, so we performed surgery rather than endovascular repair. The patient recovered fully and was discharged from the hospital. This infrarenal aneurysm with aortocaval fistula is perhaps the largest to have been treated successfully by means of open surgery. In addition to our patient's case, we discuss the history and treatment considerations of this rare combined condition.

[Deep venous thrombosis caused by congenital inferior vena cava agenesis]

Congenital agenesis of the inferior vena cava, although rare, is found preferentially in young patients with proximal deep venous thrombosis. Exact diagnosis can be made thanks to enhanced computed tomography scan and/or magnetic resonance imaging, while Doppler ultrasonography is insufficient to establish an inferior vena cava malformation. A consensus has not yet been established for the treatment but lifelong anticoagulation with elastic stocking support to prevent post-thrombotic syndrome is commonly considered in most cases. We report a case of an unprovoked deep venous thrombosis caused by a congenital agenesis of the inferior vena cava localized to the infrarenal segment, in a 24-year-old man. An anticoagulation with low molecular weight heparin was started and prolonged oral anticoagulation was prescribed. In the absence of the usual thrombotic risk factors, the presence of an inferior vena cava anomaly should be considered.

Aorto-caval fistula resulting from an abdominal aortic aneurysm: A case report from the Emergency Department of Izmir Bozyaka Training and Research Hospital, Turkey

The rupture of an abdominal aortic aneurysm into the inferior vena cava with fistula formation is a rare condition but is associated with high mortality. Classical symptoms and findings vary in a wide range, and early diagnosis and intervention can be life-saving. In this study, we present a case of abdominal aortic aneurysm associated with aorto-caval fistula formation accompanied by mortality.

Various congenital anomalies of the inferior vena cava: review of cross-sectional imaging findings and report of a new variant

The inferior vena cava (IVC) is an important structure receiving a large amount of venous return and is associated with various congenital disorders. Advances in diagnostic imaging and its increasing accessibility have led to an increase in the incidental detection of IVC anomalies. Congenital anomalies of the IVC are not uncommon and are occasionally critical to treatment planning. However, they are frequently overlooked in abdominal imaging. The IVC is composed of four segments (intrahepatic, suprarenal, renal, and infrarenal), and each segment arises from different embryonic structures in a complex process. Anomalies of the IVC can be classified according to the involved segment. Familiarity with the variety of IVC anomalies seen on imaging is vital for correctly diagnosing and managing patients in daily practice.

Abernethy malformation: Single-center experience from India with review of literature

Abernethy malformation is a rare congenital anomaly in which there is direct communication between the portal and systemic venous circulation. The clinical presentation ranges from asymptomatic with incidental detection on imaging to secondary complications of disease or related to associate anomalies. This is a retrospective analysis of data from nine patients with Abernethy malformation at a single center. This is a referral center for Pediatric Cardiology and for Hepatobiliary and Pancreatic Surgery. The patients presented to the Pulmonary Hypertension Clinic/the Hepatobiliary Surgery Clinic. Out of nine patients, four were male. Type II Abernethy malformation was present in five patients whereas three patients had type I malformation. One of the patients had communication between inferior mesenteric vein and internal iliac vein. Five out of nine patients were erroneously diagnosed as idiopathic primary pulmonary hypertension and were treated with vasodilators. One patient required living donor liver transplant. One patient was managed with surgical shunt closure whereas two patients required transcatheter shunt closure. The rest of the patients were managed conservatively. Abernethy malformation is more common than previously thought and the diagnosis is often missed. There are various management options for Abernethy malformation, which includes surgical or transcatheter shunt closure and liver transplant. Management of Abernethy malformation depends upon type, presentation, and size of shunt.

Atrial flutter ablation by femoral approach in a woman with azygos continuation of an interrupted inferior vena cava and dual chamber pacemaker

This report describes a case of isthmus-dependent atrial flutter ablation by the femoral approach in a 54-year-old woman with a previously unknown absence of the inferior vena cava (IVC) and dual chamber pacemaker. Despite looping of the catheters, ablation and termination of atrial flutter were performed successfully without function alteration of the pacemaker leads.  This is the first report of an inferior-to-superior approach for ablation of atrial flutter in the absence of the perihepatic IVC with the presence of chronic indwelling leads in the area targeted for radiofrequency.

[Aorto-cava fistula complicating abdominal aorta aneurysm]

We report here a case of aorto-cava fistula complicating the rupture of a sub-renal aortic aneurysm into the inferior vena cava, which is a rare complication of aortic abdominal aneurysms with often-fatal outcome. Abdominal computed tomography with multi-planar reconstructions remains the firstline-imaging tool allowing positive diagnosis and preoperative planning. Treatment may be surgical or endovascular.

Double venous compression due to duplicated inferior vena cava-induced right common iliac vein thrombosis

Venous compression syndromes are caused by extrinsic venous compression of anatomical structures, such as the adjacent arteries and bones. Chronic venous compression and pulsative vibratory arterial pressure accelerate the development of deep vein thrombosis. Herein, we report the first case of double venous compressions due to a duplicated inferior vena cava-induced right-sided common iliac vein thrombosis. The thrombus was induced by left-sided inferior vena cava entrapment and right-sided common iliac vein compression, resembling nutcracker syndrome and May-Thurner syndrome, respectively. Bypass flow of the right inferior vena cava rendered the right lower extremity asymptomatic. Once daily anticoagulation edoxaban was effective. Congenital venous anomalies and bypass formations should be considered when a common iliac vein thrombus without symptoms in the lower extremities is observed, and a lifelong periodical follow-up is mandatory, even after remission.

Radiological features of azygos and hemiazygos continuation of inferior vena cava: A case report

RATIONALE

Azygos and hemiazygos continuation of the inferior vena cava (IVC) is uncommon. It is rare especially when it is not associated with congenital heart disease or deep venous thrombosis.

PATIENT CONCERNS

We report an interesting case of an interstitial lung disease with an interrupted IVC with azygous and hemiazygos continuation. A 67-year-old man suffered from cough and shortness of breath.

DIAGNOSES

Computed tomography revealed absence of the hepatic segment of the IVC with azygos and hemiazygos continuation. The patient did not have congenital anomalies of the remaining thoracoabdominal vasculature and viscera. The diagnosis of azygos and hemiazygos continuation of IVC was made by inferior venacavography.

INTERVENTIONS

There was no significant association between interstitial lung disease and expanded azygos and hemiazygos veins. The patient was treated with corticosteroids.

OUTCOMES

After 6 months of follow-up, the patient was asymptomatic.

LESSONS

It is important to recognize the enlarged azygos vein at the confluence with the superior vena cava and in the retrocrural space to avoid misdiagnosis as a right-sided paratracheal mass or retrocrural adenopathy.

Hepatocellular Carcinoma Migrating to the Right Atrium through the Inferior Vena Cava

Interesting Medical Image

Disabling portosystemic encephalopathy in a non-cirrhotic patient: Successful endovascular treatment of a giant inferior mesenteric-caval shunt via the left internal iliac vein

Hepatic encephalopathy is suspected in non-cirrhotic cases of encephalopathy because the symptoms are accompanied by hyperammonaemia. Some cases have been misdiagnosed as psychiatric diseases and consequently patients hospitalized in psychiatric institutions or geriatric facilities. Therefore, the importance of accurate diagnosis of this disease should be strongly emphasized. A 68-year-old female patient presented to the Emergency Room with confusion, lethargy, nausea and vomiting. Examination disclosed normal vital signs. Neurological examination revealed a minimally responsive woman without apparent focal deficits and normal reflexes. She had no history of hematologic disorders or alcohol abuse. Her brain TC did not demonstrate any intracranial abnormalities and electroencephalography did not reveal any subclinical epileptiform discharges. Her ammonia level was > 400 mg/dL (reference range < 75 mg/dL) while hepatitis viral markers were negative. The patient was started on lactulose, rifaximin and low-protein diet. On the basis of the doppler ultrasound and abdomen computed tomography angiography findings, the decision was made to attempt portal venography which confirmed the presence of a giant portal-systemic venous shunt. Therefore, mechanic obliteration of shunt by interventional radiology was performed. As a consequence, mesenteric venous blood returned to hepatopetally flow into the liver, metabolic detoxification of ammonia increased and hepatic encephalopathy subsided. It is crucial that physicians immediately recognize the presence of non-cirrhotic encephalopathy, in view of the potential therapeutic resolution after accurate diagnosis and appropriate treatments.